Medical Billing Representative (Prior Auth, AR)Medical Billing Representative (Prior Auth, AR)

Key Achievements:

o Explain long-term care policy details to policyholders or their representatives (coverage, eligibility, exclusions o Provide clarification on premium payments, policy renewals, or lapses. o Investigate and resolve billing errors, claim denials, or policy disputes. o Assist with understanding benefit usage, such as how much of their policy benefit has been used or what’s still available. o Document interactions in the system for accurate recordkeeping and follow-up.

Key Achievements:

o Bimonthly Call calibration with TLs, QAs, Trainers, Managers and Clients from all sites. o Validate Case error received from nurse reviewers and upload it on a shared drive for reporting and P4P purposes. o Surveillance Audit (Call Quality Audit). o Doing 1on1 coaching. o Answering Supervisor Calls. o Coordinating with onshore POC for urgent cases o Weekly Meeting for recent update and reiteration of most common errors received and QA markdowns o Create and update process Map and workflows. o Receiving inbound calls from Doctor offices and Hospitals, checking pre- authorization requirement o Creating Prior-Authorization case based on the request received

Key Achievements:

o Receiving inbound calls from Doctor Offices and Hospitals, checking pre- authorization requirement. o Creating Prior-Authorization case based on the request received. o Walkthrough in creating referrals using Web portal. o Reviewing member Eligibility, benefits and provider participating status (overview). o Escalating verified urgent and critical cases. o Open communication with SME, TLs and Pre-service nurses for high priority case. o Adhere to HIPAA compliance

Key Achievements:

o Daily review of "Aging Buckets" to identify which claims are outstanding and prioritize them before they hit Timely Filing limits. o Navigating insurance websites to verify claim receipt and current status. o Investigating EOBs and ERAs to find out why a claim was denied. o Fixing front-end errors like incorrect patient demographics, invalid member IDs, or missing modifiers. o Speaking directly with insurance adjusters to dispute underpayments or push for a reconsideration of a denied claim. o Entering payments from paper checks (manual) and processing Electronic Remittance Advices (ERAs) from insurance companies. o Posting co-pays, deductibles, and co-insurance payments. o Organizing payments into "batches" and ensuring the total amount posted in the system matches the total amount deposited in the bank. o Ensuring payments are applied to the specific date of service and specific procedure code (CPT) to prevent "unapplied" cash. o Applying the correct "write-off" amounts based on the healthcare provider's contract with the insurance company.

Key Achievements:

o Resolves problems by clarifying issues; researching and exploring answers and alternative solutions; implementing solutions. o Processing patients order of Durable Medical Equipment. o Meeting Quality assurance requirement and other key performance metrics. o Adhere to HIPAA compliance